It’s pretty clear that you don’t need to do an LP to rule out meningitis in simple febrile seizures. But what about complex febrile seizures? What if you consult a Neurologist and they recommend one? Read on to find answers to this pertinent question.
First, what defines a complex febrile seizure
Complex febrile seizures are generally defined as follows;
- Focal onset Which admittedly can be hard to define since you are relying on caregiver report
- Prolonged >15 minutes (which is a really long time, though some advocate for a 10 minute limit)
- Recurrent within 24 hours
In most series ≤20% of febrile seizures are complex, and in general focal features are more rare than a prolonged seizure. Most kids who have a complex febrile sierra do so their first time. This doesn’t mean that all subsequent febrile seizures will be complex. Conversely, it is more rare for a simple febrile seizure child to have a subsequent complex one – though it does happen about 5% of the time.
Complex febrile seizures are important, as children that have them are more likely to have abnormal development and be younger in age, see Hesdorffer et al. for more information.
This is different than febrile status epilepticus
Febrile status epileptics seizures last >30 minutes. There is evidence that an LP is warranted in this group, but this is beyond the scope of this post. So let’s move on.
Is there any evidence on the need for LP?
The answer is yes, there’s evidence, and no, you probably don’t need to do an LP. Let’s take a look at a couple of studies.
This was a retrospective cohort of 526 children with complex febrile seizures. The rate of LP was 64%, though the data were from 1995-2000, crossing vaccine eras. Only 14 (2.7% [95% confidence interval [CI]: 1.5-4.5]) has CSF pleocytosis. Only 3 of these kids had bacterial meningitis. One had S. pneumo, and was apneic with a bulging fontanelle, and another was unresponsive. Another with CSF pleocytosis had a positive blood culture for S. pneumo, but a negative CSF culture. No patients in this cohort without an LP performed came back to the hospital with bacterial meningits.
This retrospective cohort of 193 children 6 months to 5 years with first complex febrile seizures between 2005-2010 saw 136/193 (70%) getting LPs, with only 1/14 that had pleocytosis on the CSF having bacterial meningitis. LPs were more likely in kids with seizure focality, status epilepticus, or a need for intubation. 43/193 had ≥2 seizures in 24 hours. In my practice I see this more often than locality or length >15 minutes. None of the 17/43 that had an LP performed had bacterial meningitis.
This multi center retrospective study of 839 children with complex febrile seizures saw rates of bacterial meningitis (0.7%) and HSV meningitis (0%). All 5 patients with bacterial meningitis had signs and symptoms of meningitis.
A large national database report of almost 29,000 children with complex febrile seizures from 2007-14 saw declining rates of LP overall. The rate of CSF infection (not specified virus or bacteria unfortunately) was 0.3% (80 encounters, 95% CI = 41-112). They also noted that 51.0% (95% CI = 47.9%-54.1%) were admitted. This study was limited by the data source, but also shows on a macro level just how rare CSF infection is.
Are there any guidelines? I like guidelines…
The answer is no, not really… See the AAP’s guideline for simple febrile seizures below. We can abstract some useful information form it, and the above studies which I’ll get to in the recommendations section at the end.
Notably, the AAP’s guideline does not apply to children who have had a complex febrile seizure. In general, the AAP says the following about LP;
“A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms (eg, neck stiffness, Kernig and/or Brudzinski signs) or in any child whose history or examination suggests the presence of meningitis or intracranial infection.”
This is a no-brainer and I believe that it extrapolates to complex febrile seizures as well. Children with focal abnormalities on euro exam, a bulging fontanelle + ill appearance, a stiff neck (though don’t mistake a stiff neck with not being able to look up due to a retropharyngeal abscess), and Kernig (positive when the thigh is flexed at the hip and knee is at 90 degrees – followed by back/neck pain when the knee is extended) and Brudzinski (when the neck is flexed the hips and/or knees will flex as well). This is a moderate to high level recommendation.
“In any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended) or when immunization status cannot be determined because of an increased risk of bacterial meningitis.”
Remember, you need 2, 4 and 6 month Prevnar and Hip to be considered reasonable immunocompetent. This one comes down to how well the child looks, and how normal their exam is. Be sure to make your decision based on how the child looks when they are afebrile. This recommendation is also a low level one, based on expert opinion and case reports.
“A lumbar puncture is an option in the child who presents with a seizure and fever and is pretreated with antibiotics, because antibiotic treatment can mask the signs and symptoms of meningitis.”
It is relatively unlikely that a child with a simple febrile seizure will be on an antibiotic already, but it does happen. This would probably be in the context of otitis media, or maybe UTI. Remember that most febrile seizures happen closer to the onset of the illness, so it’s possible that the child is on a course of antibiotics that they might not need, or are close to completing from a recent diagnosis. nevertheless this is a low level recommendation, based on expert reasoning and case reports, and does not routinely factor into my LP vs not decision making.
Conclusion & Recommendations
- Make sure you accurately define what type of febrile seizure you are dealing with; simple versus complex, and know that it can be hard to nail down the details in the history (especially duration and focality at onset).
- The likelihood of bacterial meningitis (or even viral meningitis) in the well-appearing child with a history of a complex febrile seizure(s) is incredibly low and you don’t need to do an LP, even if the child is not 100% up to date on vaccines or is concurrently on an antibiotic.
- Conversely, if the child is ill, altered, ad has meningeal signs do the LP if they are stable enough to obtain it. All of the kids >6 months that I’ve seen with bacterial meningitis have looked unwell (at best).
Subcommittee on Febrile Seizures; American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-94. doi: 10.1542/peds.2010-3318.